Cardio part 3 Flashcards
Pathophys of peripheral vascular dz
Primarily the result of atherosclerosis
May manifest acutely when thrombi, emboli, or acute trauma compromises perfusion
Etiology of PVD
Coexisting conditions: CAD AFib Cerebrovascular dz Renal disease RFs: Smoking HLD DM Hyperviscosity
Hx-PVD
Intermittent claudication may be the sole manifestation of early symptomatic PVD
Aortoiliac- pain in the thigh and buttock
Femoropopliteal- pain in the calf
Could also present as the hip or leg “giving out” after a certain period of exertion
Pain does not usually occur with sitting or standing
Ischemic rest pain is more worrisome
Erectile dysfunction can be a potential early indicator
Leriche syndrome- intermittent claudication, impotence, and significantly decreased or absent femoral pulses
PE of PVD
Pulselessness Paralysis Paresthesia Pain Pallor Check all pulses Do Allen test Skin may have an atrophic, shiny appearance and may demonstrate trophic changes
Workup of PVD
CBC CMP Doppler CT may be of use to emergency med if MRI cannot be used ABI
Tx of PVD
Attention to the ABCs, IV access, and obtaining baseline lab studies
Obtain EKG and CXR
Tx of thrombi or emboli- heparin
Consider surgical referral with acute leg pain correlated with a cool distal extremity, diminished or absent distal pulses, and an ankle blood pressure <50 mm Hg
Pathophys of aortic stenosis
When the valve becomes stenotic, resistance to systolic ejection occurs and a systolic pressure gradient develops between the left ventricle and the aorta
Etiology of aortic stenosis requiring surgery
Common causes <70 yo in order: Bicuspid AV Postinflammatory Degenerative Unicommisural Hypoplastic Indeterminate Common causes >70 yo in order: Degenerative Bicuspid Postinflammatory Hypoplastic
H/o aortic stenosis
Usually has an asymptomatic latent period of 10-20 years MC initial complaint is dyspnea CP Heart failure Syncope
PE of aortic stenosis
Carotid arterial pulse typically has a delayed and plateaued peak, decreased amplitude and gradual downslope (pulsus parvus et tardus)
Jugular venous pulse may show prominent a waves
A2 usually diminished or absent
Paradoxical splitting of the S2
Prominent S4 can be present
Crescendo-decrescendo systolic murmur
Rough low-pitched sound that is best heard at the second intercostal space in right upper sternal border
Radiates to carotid artery
Workup of aortic stenosis
EKG CXR CMP Cardiac markers CBC TTE Cardiac cath and coronary arteriography BNP
Tx of aortic stenosis
Address ABCs
Perform CPR if in cardiac arrest
With acute sx, hospital admission, telemetry/ICU admission, and cardiology consultation should be considered
Heart failure- oxygen, cardiac and oximetry monitoring, IV access, loop diuretics, nitrates, morphine, and ventilatory support
Percutaneous balloon valvuloplasty is used as a palliative measure
Aortic valve replacement
Pathophys of aortic regurgitation- acute
The LV does not have sufficient time to dilate in response to the sudden increase in volume. As a result, LV end-diastolic pressure increases rapidly, causing an increase in pulmonary venous pressure and altering coronary flow dynamics. As pressure increases throughout the pulmonary circuit, the pt develops dyspnea and pulmonary edema.
Pathophys of aortic regurgitation- chronic
Chronic AR causes gradual left ventricular volume overload that leads to a series of compensatory changes, including LV enlargement and eccentric hypertrophy. LV dilation occurs through the addition of sarcomeres in series, as well as through the rearrangement of myocardial fibers. As a result, the LV becomes larger and more compliant, with greater capacity to deliver a large stroke volume that can compensate for the regurgitant volume
Etiology of acute aortic regurgitation
Infective endocarditis Chest trauma Post-TAVR LVAD implantation Aortic dissection Prosthetic valve malfunction
Etiology of chronic aortic regurgitation
Bicuspid aortic valve Certain wt loss meds, such as fenfluramine and dexfenfluramine Rheumatic fever Ankylosing spondylitis Behcet dz Giant cell arteritis RA SLE Takayasu arteritis Whipple disease Marfan syndrome Ehlers-Danlos syndrome Floppy aortic valve Aortic valve prolapse Sinus of Valsalva aneurysm Aortic annular fistula
H/o acute aortic regurgitation
Sudden, severe SOB
Rapidly developing HF
CP
H/o chronic aortic regurgitation
Long-standing asymptomatic period that may last for several years Compensatory tachycardia may develop Severe chronic AR: -Palpitations -Uncomfortable awareness of the heartbeat -SOB -CP -Sudden cardiac death
PE of acute aortic regurgitation
Tachycardia Peripheral vasoconstriction Cyanosis Pulmonary edema Arterial pulses alternans Early decrescendo diastolic murmur best heard leaning forward in full expiration Austin-Flint murmur
PE of chronic aortic regurgitation
DBP <60, with pulse pressures often exceeding 100 mm Hg
Becker sign
Corrigan pulse
de Musset sign
Hill sign
Duroziez sign
Muller sign
Quincke sign
Traube sign
PMI may be diffuse or hyperdynamic but is often displaced inferiorly and toward the axilla
Peripheral pulses are prominent or bounding
S3 gallop if LV dysfunction is present
High-pitched murmur that is loudest at the left sternal border
Austin-Flint murmur
Becker sign
Visible systolic pulsations of the retinal arterioles
Corrigan pulse
Abrupt distention and quick collapse on palpation of the peripheral arterial pulse
de Musset sign
Bobbing motion of the pt’s head with each heartbeat
Hill sign
Popliteal cuff systolic BP 40 mm Hg higher than brachial cuff SBP
Duroziez sign
Systolic murmur over the femoral artery with proximal compression of the artery with proximal compression oft he artery, and diastolic murmur over the femoral artery with distal compression of the artery
Muller sign
Visible systolic pulsations of the uvula
Quincke sign
Visible pulsations of the fingernail bed with light compression of the fingernail
Traube sign
Booming systolic and diastolic sounds auscultated over the femoral artery
Austin-Flint murmur
Low-pitched, mid-diastolic rumbling murmur
Workup for aortic regurgitation
Labs guided by clinical scenario CBC PT/aPTT Type and screen Electrolytes VDRL Lactate dehydrogenase TTE Exercise treadmill testing CXR Radionuclide imaging Aortic angiography Cardiac CT scanning and MRI EKG Cardiac catheterization
ED care of aortic regurgitation- general
Provide adequate airway management
Intubate when necessary
Consider prompt surgical intervention in acute AR
ED care of acute aortic regurgitation
Administer a positive inotrope (e.g., dopamine, dobutamine) and a vasodilator
Avoid BBs
ED care of chronic aortic regurgitation
Consider abx prophylaxis for pts with endocarditis when performing procedures likely to result in bacteremia
Administration of pressors and/or vasodilators may be appropriate
Pathophys of mitral stenosis
As the orifice size decreases, the pressure gradient across the mitral valve increases to maintain adequate flow
As the valve progressively narrows, the resulting diastolic mitral valve gradient, and hence left atrial pressure, increases
This leads to transudation of fluid into the lung interstitium and dyspnea at rest or with minimal exertion
Hemoptysis may occur if the bornchial veins rupture and left atrial dilatation increases the risk for atrial fibrillation and subsequent thromboembolism
Pulmonary HTN may develop
H/o mitral stenosis
Sx usually manifest during the third or fourth decade of life and nearly 1/2 of the pts do not recall a h/o acute rheumatic fever
Generally asymptomatic at rest during the early stage of the dz
Factors that increase HR such as fever, severe anemia, thyrotoxicosis, exercise, excitement, pregnancy, and AFib may result in dyspnea
Hoarseness can develop from compression of the left recurrent laryngeal nerve
PE of mitral stenosis
Mitral facies (pinkish-purple patches on the cheeks)
JVD
In pt with sinus rhythm, prominent a wave
RV lift palpable int he left parasternal region in the pt with pulmonary HTN
A P2 may be palpable in the 2nd left intercostal space
Loud first heart sound
Opening snap
Diastolic rumble, low-pitch, accentuated by exercise, decreases with rest and Valsalva
Second heart sound is split
Opening snap
May have Graham Steell murmur: high-pitched decrescendo diastolic murmur second to pulmonary regurgitation
Workup of mitral stenosis
Routine labs
Chest radiography
Echo- TEE
EKG
Tx of mitral stenosis
Reduce recurrence of rheumatic fever
Provide prophylaxis for infective endocarditis
Reduce sx of pulmonary congestion- diuretics for initial sx, careful use of BBs in pts with NSR
Control of ventricular rate is AFib is present
